the future of psychiatric services in california if public policy does not change e. fuller torrey,...

The Future ofPsychiatric

Servicesin California

If Public PolicyDoes Not Change

E. Fuller Torrey, MDTreatment Advocacy Center

Arlington, VAJuly 24, 2010

____________________________________

The Insanity Offense

www.treatmentadvocacycenter.org

Severe psychiatric disorders =• Schizophrenia• Schizoaffective disorders• Bipolar disorder with psychosis• Major depression with psychosis

California as leader

• 1957: Short-Doyle Act

• 1960s: Introduction of chlorpromazine (Thorazine)

• 1959–1967: Deinstitutionalization: 37,000 to 19,000 under Pat Brown (D)

• 1967: Lanterman-Petris-Short (LPS) Act

• 1970s: SF was first city completely covered by CMHCs. Westside CMHC considered a model center.

Psychiatric hospital beds in California

Psychiatric Hospital Beds in California

0

10,000

20,000

30,000

40,000

Year

Beds

1960 1970 1980 1990 2000 2010

37,000 in 1960

19,000 in 1969

10,000 in 2004

4,000 in 2010

Psychiatric hospital beds in California

• 1960: 1 psychiatric bed available for every 400 population

• 2010: 1 psychiatric bed available for every 10,000 population

• California essentially now has 4% of the psychiatric beds it had available 50 years ago

Three men who symbolize the phases of the

present disaster• Nicholas Petris: the theorist

Nicholas Petris

• Liberal Democrat from Oakland, in state legislature

• 1967 Chairman of Ways and Means Subcommittee

• 1967 Lanterman-Petris-Short (LPS) Act

Nicholas Petris

• Influenced by Thomas Szasz’ 1961 The Myth of Mental Illness

• Petris: “We remember that throughout history some of today’s madmen can become tomorrow’s heroes.”

Nicholas Petris

In 1989 Petris acknowledged that LPS had been a mistake. When asked about follow-up of released patients:

Nicholas Petris“No, never even got off the ground. And then it was very difficult for those who tried, because they had no handle on people. There was no way they could compel them to do anything…

Nicholas Petris…They couldn’t threaten to run them in again, because of the harsh definition that we adopted and said that you don’t incarcerate someone against his will unless he’s a danger to himself or others, or he’s so gravely disabled that he just can’t take care of his normal functions. Well, that’s very severe.”



• Saul Feldman: the administrator

Saul Feldman

• PhD in psychology and public administration

• 1970 NIMH Associate Director for Community Mental Health Services

Saul Feldman“A major impetus behind the community mental health centers program, of course, was the need to develop effective alternatives to extended hospitalization in a public mental hospital.”

Saul Feldman andHarold H. Goldstein, 1971

Saul Feldman

“If feelings and emotions are so closely linked to living conditions, how then can mental health workers ignore substandard schools, poverty, overcrowding, and other environmental problems?”

Saul Feldman, 1971

Saul Feldman• Recognized CMHCs were failing as

early as 1971, e.g., acknowledged that only 16% of CMHC admissions had been in state mental hospitals.

• In 1972 ignored report documenting how some CMHCs had used the federal funds to build a swimming pool and tennis court and pay the salaries of a pool lifeguard and swimming instructor.

Saul Feldman

1978: “In short, it seems clear that community mental health centers cannot now, and will not in the near future, be able to do what the legislation requires, that failure is inevitable and that the cost of this failure may be severe.”

Saul Feldman• President and CEO,

HealthAmerica Corp of California

• CEO, United Behavioral Health,“a leading provider of emotional wellness services”

• The chairman of the parent company, United Health Care, was paid $54.1 million in 2000

Saul FeldmanThe San Francisco Chronicle reported that Feldman was living in a penthouse atop the Four Seasons Hotel.



• Saul Feldman: the administrator

• Michael Bowers: the recipient

Michael Bowers

• Born in Pittsburgh; moved to California as a child

• Worked as a sound man in concert halls and as a chauffer

Michael Bowers• In 1986, at age 24, developed

paranoid schizophrenia; thought high-level officials wanted to keep him from revealing secret information

• 1986–2001: For 11 of the 15 years was in Patten State Hospital, Atascadero State Hospital, or prison

• When in the community, refused to take medications

Michael Bowers, January 17, 2001

What is the outcome of the grand experiment

of deinstitutionalization?

1. Successful community living



1. Successful community living2. Victimization and premature death

Victimization1984: 278 individuals in LA group homes: Two-thirds “reported having been robbed and/or assaulted during the last year.”

1988: In SF: “I know one woman who has been raped 17 times.”

2006: 308 SMI individuals: in previous6 months, 26% had been robbed, raped, mugged, or assaulted

Victimization

The future:

• More individuals assaulted• More individuals robbed• More women raped

“They are rabbits forced to live in company with dogs.”




3. Homelessness

Homelessness

By the mid-1980s, California State Assemblyman Bruce Bronzan estimated that there were “between 20,000 and 50,000 adults who are chronically mentally ill and may be homeless,” a situation he labeled “morally unacceptable and just unbelievable.” …

Homelessness

… Richard Lamb added,“Probably nothing more graphically illustrates the problems of deinstitutionalization than the shameful and incredible phenomenon of the homeless mentally ill.”

HomelessnessIn LA, a 1985 study reported, 30–50% of all homeless persons were seriously mentally ill, and they were being seen in “ever increasing numbers.” The study noted, “They are defenseless and frequently victimized…beaten, robbed and raped daily…[and] often eat garbage and sleep in alley ways.” …

Homelessness… The study concluded that homeless mentally ill persons “are in part the product of the deinstitutionalization movement” and that the “new liberalized Mental Health laws [making] involuntary psychiatric treatment almost impossible…the ‘Streets’ have become ‘The Asylums’ of the 80s.”

Homelessness

A 1988 study of 529 Los Angeles street persons reported that 44% had had a previous psychiatric hospitalization; among that group, 28% obtained “some food” from garbage cans and 8% utilized garbage cans as their primary food source.” …

Homelessness

… Another study of mentally ill street persons found that 79% of them had been previously psychiatrically hospitalized.

HomelessnessIn LA in 2005, Mayor Antonio Villaraigosa visited skid row and commented, “I mean that almost looked like Bombay or something, except with more violence. There is no place [in the city] where the chaos and degradation are as pronounced. You see a complete breakdown of society.” …

Homelessness

… The LA Times called the skid row scene “a human catastrophe unfolding” and concluded that “laws intended to protect the rights of…mentally ill people are well-intended but inhumane.”

Homelessness

In 1976, columnist Mike Royko called California “the world’s largest outdoor mental asylum.”

It has now become literally true.

HomelessnessThe future:

• More homeless on the streets

• More crime: 1983 study showed that homeless persons with a previous psychiatric hospitalization had3 times more felony convictions than homeless persons without a previous psychiatric hospitalization

• Invasion of city hall




3. Homelessness4. Incarceration in jails and prisons

Incarceration inJails and Prisons

• 1972, Marc Abramson:“The criminalization of mentally disordered behavior”

• 1973, James Stubblebine: “Specific information is not available.”

Incarceration• 1980, Richard Lamb, LA

County Jail

• 1980–1993: SF Jail psychiatric services increased 99%

• 1995: LA Jail recognized as the largest de facto mental institution in the United States

Incarceration

• Overcrowding

• Bizarre behavior

• Victimization of SMI prisoners

• Suicide

• Costs

Consequences

IncarcerationThe future:• Percentage of SMI in jails and

prisons will increase to 33% or higher

• Increase in jail and prison suicides

• Increase in costs, especially due to lawsuits

• Sheriffs may begin refusing to take SMI prisoners

• Renovating/building prisons as mental hospitals





5. Interactions with the police

Interactions with the Police

• 1987–1993: annual calls to LA Police Mental Evaluation Unit increased from 12,613 to 54,737

• 1992–2001: Ventura County police killed 32 people, 18 of whom were SMI

• 1996 cost study: City police departments in CA were spending $445 million/year “on handling mentally ill offenders”

Interactions with police

The future:

• Police will increasingly become social workers

• ? Separate police department?

• Increasing numbers of SMI killed by police and police killed by SMI

• Increasing costs for police departments





5. Interactions with the police

6. Homicides

U.S. studies of homicides by SMI

Matejkowski et al, J Am Acad Psychiatry Law 2008;36:74–86

• 1990–2002, sample of all individuals in Indiana convicted of homicide

53/518 (10.2%) of homicides had schizophrenia, BP, or other psychosis

Homicides

U.S. studies of homicides by SMI

Wilcox, Am J Forensic Psychiatry 1985;6:3–15

• 1978–80 in Contra Costa County, CA:

7/71 (10%) of the people who had committed a homicide had schizophrenia

Homicides

Examples of prominent homicides

Homicides

1970: John Frazier, Santa Cruz1973: Herb Mullin, Santa Cruz1976: Edward Allaway, Fullerton1988: Dorothea Montalvo, Sacramento1993: Linda Scates, Walnut Creek1999: Steven Abrams, Costa Mesa1999: Julie Rodriguez, Sacramento2000: Marie West, Van Nuys

Homicides: examples

2001: David Attias, Santa Barbara2001: Scott Thorpe, Nevada City2005: Lashuan Harris, San Francisco2006: Jennifer San Marco, Goleta2006: Lawrence Woods, Pismo Beach2008: Lee Leeds, Santa Maria2009: Charlie Sekona, San Francisco2010: Layla Trawick, West Hollywood

Homicides

• A total of 10,240 deaths over 39 years

• An average of 263 deaths each year

• An average of 1 death every 1.4 days

Total homicides in CA, 1970–2008:

If individuals with SMI were responsible for 10%, that would be:

102,396

Homicides

Comments on homicides

Kenneth Springer, foreman of the 1973 jury that convicted Herb Mullin:

Springer likened the effects of LPS to “releasing known killers from our prisons, arming them, and then turning them loose on society.” …

Homicides: comments

… “The closing of our mental hospitals,” he added, “is, in my opinion, insanity itself.” Finally, Springer asked, “Was Herb Mullin any more responsible for those 13 lives than those public officials who perpetuate this insane law that allowed him to be free to kill 13 people?”

Homicides

State Department of Mental Health comment on homicides

Dr. Andrew Robertson, testifying in 1973 before a select committee of the legislature:

“It [LPS] has exposed us as a society to some dangerous people; no need to argue about that. People whom we have released have gone out and killed other people, maimed …

Homicides: comments… other people, destroyed property; they have done many things of an evil nature without their ability to stop and many of them have immediately thereafter killed themselves. That sounds bad, but let’s qualify it…the odds are still in society’s favor, even if it doesn’t make patients innocent nor the guy who is hurt or killed feel any better.”

Homicides

The future:

• Increasing number of homicides by individuals with SMI who are not being treated: 15%? 20%?

• Who gets killed?

1. What is its magnitude?There are 4 million seriously mentally ill individuals in the U.S. (population 302 million)Therefore: Per

1,000 pop

Permillion pop

Number of seriously mentally ill individuals

13 13,000

Number of seriously mentally ill individuals who are problematic (10%)

1.3 1,300

Number of seriously mentally ill individuals who are dangerous (1%)

0.13 130

Solving the Problem

What does this translate to?California37 million

Bay Area2.5 million

Number of seriously mentally ill individuals

481,000 32,500

Number who are problematic (10%)

48,100 3,250

Number who are dangerous (1%)

4,810 325

• History of past violence

• Substance abuser

• Noncompliance with medication/anosognosia

2. Identify the target population: 10% of SMI

3. Why do people with severe psychiatric disorders not take

medication?The biggest single reason,

confirmed in several studies, is that they do not think they are sick. They have limited or no awareness of their illness. In neurological terms, this is

called anosognosia.

The supramarginal gyrus (BA40) has vertical lines.

The angular gyrus (BA39) has horizontal lines.

Inferior parietal lobe

Nicholas Petris’ layperson’s description of anosognosia

(from his 1989 retrospective understanding):

“Well, what are you going to say? ‘Nice seeing you?’ Well, I’ll tell you what I would say. I’d say, ‘Damn it, don’t I have a right to treatment? If I had broken a leg or had a heart attack, …

Nicholas Petris on anosognosia

… you would be swarming all over the place with doctors and nurses and this and that. Why the hell didn’t you get me treatment?’ ‘Well, because you resisted.’ ‘Well, baloney I resisted! Of course I resisted, because I didn’t know what the hell I was doing.’”

4. Implement Laura’s Law in each county

• It will decrease rehospitalization, homelessness, victimization, arrests, and violent behavior

• Thus, it will protect both individuals with SMI and the public

• It will also decrease stigma

• It will be cost-effective• Identify the target population: 10% of SMI

Effectiveness of Assisted Outpatient Treatment

Prior to being on

AOT

OnAOT

Decrease

District of Columbia

55 38 -31%

North Carolina 22 14 -36%

Ohio 133 44 -67%

Iowa 33 5 -85%

New York 100 44 -66%

North Carolina 33 5 -85%

1. Decrease in days hospitalized per year

Effectiveness of Assisted Outpatient Treatment, cont’d

2. Decrease in homelessness:19% to 5% (NY)

3. Decrease in victimization:42% to 24% (NC)

4. Decrease in arrests:45% to 12% (NC)30% to 5% (NY)

5. Decrease in violent behavior:42% to 27% (NC)15% to 8% (NY)

Multiple studies have shown that violent acts committed by individuals with severe

Andrea YatesRussell Weston

Andrew Goldstein

psychiatric disorders are the single largest cause of this stigma.

The 1999 Surgeon General’s Report on Mental Health cited studies showing that “the perception of people with psychosis as being dangerous is stronger today than in the past” (p. 7).

Percentage of people who believe that mentally ill

persons are violent1950: 13% 1996: 31%

5. Focus on costs

• Mental illness–associated costs of Medicaid, Medicare, SSI, and SSDI are among the fastest growing costs in the federal budget.

Costs

• NIMH studies: SMI are 13% of all mental disorders yet utilize 40% (1993 study) or 58% (2000 study) of all treatment costs.

• English study of schizophrenia: the sickest 10% of patients utilize 80% of costs.

Petrila et al, 2010

Florida study of 813 individuals with psychoses who were arrested calculated their median incarceration and treatment costs as $11,684 per year.

Costs

Costs

High-cost Medicaid enrollees with diagnoses of SMI or mental retardation have average costs of $61,794 per year.

Sommers and Cohen, 2006

Social costs of violent crime:• $925,000 per violent crime

(Congressional testimony, 2006)• Herb Mullin

Costs

$1 m (to date) in CA prison costs

Social costs to his own family

Social costs to the families of his 13 victims, 8 of whom were under age 25

Average cost of intensive psychiatric care:• Antipsychotic meds:

$800–$5,000/year

• Assertive community treatment (ACT): $20,000–$30,000/year

Costs

Impediments tosolving the problem

1. Civil libertiesIn 1976, Stephen J. Morse at the USC School of Law said: “Our society should be willing to absorb a certain amount of violent behavior in order to preserve civil liberties for all of us.”

Impediments

2.Political correctness

“Consumers”

“People with lived experience”

Impediments

3. LeadershipState: Stephen Mayberg, PhD

Feds: Center for Mental Health Services (CMHS)

Substance Abuse and Mental Health Services Administration (SAMHSA)

California Psychiatric Association

California NAMI

Politicians: Mayor Gavin NewsomeSupervisor Michela

Alioto-Pier

Center for Mental Health Services:

what they fund

valid, desirable condition … a healthy transformational process that should be facilitated instead of treated.”

Conferences such as the one at which a speaker described schizophrenia as “a healthy,

$1.3 million to the National Empowerment Center, whose directors believe that “mental

illness is a coping mechanism,not a disease” and that “the covert mission of the mental health system … is social control.”

What Can YOU Do?

• Advocate as a group: California Treatment Advocacy Coalition

• Calculate costs

• Follow up discharged patients

• Publicize the consequences of failing to treat

• Write, speak out, write, speak out, then write and speak out again

• Defend the civil rights of patients

The paramount civil right of the patient should be that of adequate treatment.Stephen Rachlin,

1974

the future of psychiatric services in california if public policy does not change e. fuller torrey,...

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